by E. Fuller Torrey, M.D.
April 2002
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Evidence is accumulating that the occurrence of severe psychiatric disorders,
especially schizophrenia and bipolar disorder, may be increasing. The
most visible manifestation of this is the increasing number of severely
mentally ill individuals among the homeless population and in the nation's
jails. Multiple studies have reported that at least one-third of the approximately
600,000 homeless individuals have a severe psychiatric disorder, and there
are suggestions that the problem is getting worse.
Similarly, a 1999 U.S. Department of Justice study reported that 16% of
inmates in local jails and state prisons -- 275,900 individuals -- had
been treated psychiatrically (Ditton, 1999). There are, therefore, five
times more psychiatric patients in jails and prisons than the 55,000 remaining
patients in state psychiatric hospitals. Headlines are increasingly proclaiming
statements such as: "Mental Illness Behind Bars: A Tragic Situation
Getting Worse" (Kupers, 2000).

Another measure of the increasing number of individuals
with severe psychiatric disorders is the number of these individuals on
supplemental security income (SSI) and social security disability insurance
(SSDI), the two federal programs for the support of disabled individuals.
The number of individuals in the category "mental disorders other
than mental retardation" increased from 1.1 million in 1985 to 2.9
million in 1998, a 164% increase during a time in which the U.S. population
increased only 13%. The "mental disorders" category is both
the largest and the fastest-growing diagnostic category for both the SSI
and SSDI programs.

Increasing numbers of individuals with severe psychiatric disorders are
also suggested by the experience of managed care companies assuming responsibility
for state psychiatric programs. In state after state, managed care companies
have underestimated the number of individuals with severe psychiatric
disorders who require services, with dire fiscal consequences. Typical
is a statement from the press regarding the January report from the state
of Maryland discussing the failed managed care program for Maryland's
mentally ill Medicaid patients: "But the state greatly underestimated
demand, and the system was soon overwhelmed" (Becker and Hedgpeth,
2002).

The strongest evidence that severe psychiatric disorders may be increasing
comes from the Epidemiologic Catchment Area (ECA) study, carried out in
the early 1980s, and the National Comorbidity Survey (NCS), carried out
in the early 1990s. In a 1999 discussion, Darrel Regier, M.D., co-author
of the ECA study, said the study found that, after accounting for duplicate
diagnoses, 2.2% of adults (ages 18 years and over) met diagnostic criteria
for schizophrenia or bipolar disorder over a one-year period. A recent
reanalysis of this study revised this estimate to 1.7% (Narrow et al.,
2002). This translates into a prevalence rate of 12 to 16 per 1,000 total
population, not including any mentally ill adults with other severe psychiatric
disorders such as major depression or severe obsessive-compulsive disorder.
The NCS study reported that 2.6% of adults had a "severe and persistent
mental illness [SPMI]," defined as including schizophrenia; bipolar
disorder; severe forms of depression, panic disorder and obsessive-compulsive
disorder; and autism (Kessler et al., 1996). This translates into 19 adult
individuals with SPMI per 1,000 total population.

Although comparisons of rates over time are fraught with diagnostic and
other methodological pitfalls, the 12 to 19 per 1,000 rate contrasts sharply
with prevalence surveys done in earlier years. For example, the 1958 Hollingshead
and Redlich study of New Haven, Conn., one of the ECA study sites, reported
a rate of 4.2 individuals who were being treated for schizophrenia and
affective psychoses per 1,000 total population. Similarly, a census study
of Baltimore, another ECA study site, found a rate of 7.1 individuals
with psychosis or with psychotic traits, both treated and untreated, per
1,000 total population (Lemkau et al., 1942).

The most complete enumeration of severe psychiatric disorders ever carried
out by the U.S. Census Office was done in 1880. Because of widespread
fears at the time that insanity was increasing, census enumerators were
given special forms and extra pay to identify all severely mentally ill
people, including querying neighbors of the person in question. In addition,
all 100,000 physicians in the United States were asked to report "all
idiots and lunatics within the sphere of their personal knowledge,"
and over 80% did so. Insanity was classified by seven subtypes using definitions
supplied by the New England Psychological Association. All duplication
between the enumerator and physician lists was eliminated.

A total of 91,997 insane people were identified. Of these, 38,047 were
in asylums, an increase of 115% in hospitalized insane since the 1870
census. The prevalence of insane people, both hospitalized and living
in the community, was 1.83 per 1,000 total population. In 1880, asylum
superintendent Foster Pratt called that increase an "important and
alarming fact a great question of public health that demands careful
study" (as cited in Grob, 1980). And yet the ECA study from 1980
reported a prevalence rate for schizophrenia and bipolar disorder that
was almost 10 times higher than the 1880 prevalence rate.

Concern about increasing rates of severe psychiatric disorders in the
United States dates back to the early 19th century. In 1817, for example,
an unknown writer in the September issue of North American Review facetiously
suggested that "instead of a hospital for the insane, this [proposed]
establishment be exclusively appropriated to the use of the sane,"
since the sane would soon be a small minority. By 1833, one observer noted,
"Insanity was once a rare occurrence" but "is no longer
rare" (Fuller, 1833, as cited in Jimenez, 1987). State hospitals
were built, despite substantial resistance from the taxpayers, at an increasing
rate to accommodate the increasing numbers, but the hospitals were filled
as quickly as they opened. Dorothea Dix urged state legislatures to build
more hospitals, and in 1840 the federal government added an enumeration
of insane people to the decennial census.

Edward Jarvis, a prominent psychiatrist of the 1800s, presented a paper
to his fellow asylum superintendents in which he asserted, "Insanity
is an increasing disease" and that this "corroborates the opinion
of nearly all writers" (Jarvis, 1852). In the January 1845 issue
of North American Review, a review of I. Ray, M.D.'s, book A Treatise
of Medical Jurisprudence of Insanity also noted the "great prevalence
of the disease of insanity, and especially its remarkable apparent increase
of late years." Between 1880 and 1887, an additional 15 state asylums
opened. Most of the existing asylums had been enlarged, some multiple
times. In 1870, there had been just two asylums with more than 1,000 patients
each; by 1890, there were 17 such asylums, and by 1910 there were 75.
Asylum superintendent William Godding, in an 1890 address to his colleagues,
reflected on "the rising tide of indiscriminate lunacy pouring through
the wards, filling every crevice, rising higher and higher until gradually
most distinctions and landmarks have been blotted out."

The increasing prevalence of severe psychiatric disorders, as measured
by hospitalization rates, continued steadily until the mid-20th century.
The increase was unaffected by World War I, Prohibition, the Great Depression
or World War II. Much discussion took place, both among psychiatrists
and among the lay public, regarding what might be causing the increase
in insanity. Proposed causes included genetics, increasing alcohol use,
urbanization, industrialization, increased immigration and various concomitants
of civilization that might have caused an overload on the brain. In 1916,
North American Review called rising insanity "the Apocalyptic Beast"
but reassured readers, "Let us be tranquil. The human race is not
all going mad" (Harvey, 1916).

A century ago, rising insanity was a major public issue. Yet today, despite
the fact that studies suggest the prevalence of severe psychiatric disorders
is much higher than a century ago, the issue is never raised. Historians
such as David Rothman (1971) assured us, "The rate of insanity in
this country has remained constant from before the Civil War to the present,"
and this assumption, implicit or explicit, is included in every psychiatric
textbook. Why did this important issue disappear?

There are several reasons. In the first half of the 20th century, the
issue of increasing insanity was rendered irrelevant by beliefs in eugenics
and mental hygiene. Insofar as insanity was caused by genetics, restricting
reproduction and sterilizing psychiatric patients would solve the problem.
Insofar as insanity was caused by bad parenting and early childhood experiences,
education for parents and psychotherapy for those afflicted would solve
the problem. Despite eugenics and mental hygiene, however, insanity continued
to relentlessly increase.

In 1953, Herbert Goldhamer and Andrew Marshall published Psychosis and
Civilization, which claimed, "There has been no long-term increase
during the last century in the incidence of psychoses of early and middle
life." They further noted that their conclusion that no increase
had taken place was consistent with psychoanalytic theories "that
view the functional psychoses as resulting from repression of basic human
drives." The conclusion of Psychosis and Civilization was subsequently
widely quoted by textbooks of psychiatry despite the fact that its data
appear to contradict the authors' interpretation of it. In an incisive
analysis, William Eaton (1980) showed that the authors had used highly
selective figures "to support the hypothesis that the rates have
not changed."

From the 1960s on, the question of increasing insanity was explained
in sociological and Marxist terms. Michel Foucault's influential 1961
Madness and Civilization was followed by books by Andrew Scull, Rothman
and a host of other writers who claimed that insanity had not increased.
Instead, they said that the 19th-century insane asylums had been built
to rid society of "the non-able-bodied poor" (Scull's phrase)
or "the deviant and the dependent" (Rothman's phrase). Despite
having no factual basis, these views have been remarkably influential.
When one examines the historical records, it is clear that the asylums
were built in response to the rising tide of insanity, that there was
considerable resistance by taxpayers to building them, and that the individuals
being hospitalized as insane were, in fact, severely mentally ill and
not merely "the non-able-bodied poor." As Edward Shorter noted
when discussing the Foucault-Scull-Rothman thesis in his book A History
of Psychiatry (1997): "It is astonishing that this interpretation
could have achieved such currency as there is virtually no evidence on
its behalf."

The final reason why there is no current discussion of the increasing
incidence of severe psychiatric disorders is that reports from Scotland,
England and Denmark in the 1980s indicated that the incidence of schizophrenia
was in fact decreasing. Subsequent studies in Scotland found that the
apparent decrease was due to diagnostic changes (Allardyce et al., 2000).
Recent reports from Denmark (Tsuchiya and Munk Jørgensen, in press)
and England (Brewin et al., 2002) even suggest that first-admission rates
for schizophrenia have increased in recent years.

What, then, are we left with? We are left with an epidemic of schizophrenia
and bipolar disorder that presently affects 4 million Americans, four
times more than are infected with HIV. An epidemic that slowly kills by
suicide 15% of those afflicted (Goodwin and Jamison, 1990) and that costs
the nation over $110 billion each year in direct and indirect costs (Wyatt
and Henter, 1995; Wyatt et al., 1995). An epidemic that is so insidious
and ingratiating that it is barely noticed, an invisible plague. An epidemic
that increased as much as 10-fold over the last century and that appears
to still be increasing.

Dr. Torrey is executive director of the Stanley Medical Research Institute
and co-author of The Invisible Plague: The Rise of Mental Illness from
1750 to the Present, on which this article is based.

United States Census Office, 10th Census (1880), Vol. XXI: Report on
the Defective, Dependent, and Delinquent Classes of the Population of
the United States. Washington, D.C.: U.S. Government Printing Office.